Payment Integrity RN
Company: Cambia Health
Posted on: May 17, 2022
Payment Integrity RN
Telecommute or In Office (Only within ID, OR, UT, WA)
Payment Integrity RN conducts post service review of claims in
prepayment, post payment or audit capacity to ensure appropriate
clinical review, reimbursement of claims and accuracy of coding.
Applies resources, including but not limited to, internal medical
and reimbursement policies and correct coding guidelines based on
national standards to support claim review and determination.
* Applies nursing expertise to ensure compliance with medical and
reimbursement policies and/or guidelines and accepted standards of
* Ensures that medical records and other documentation requirements
follow federal regulations, company policies and industry
* Serves members and providers by performing reviews of claims
along with corresponding medical records (when required) to ensure
appropriate payment of claims.
* Consults with physician advisors to ensure clinically appropriate
* Collaborates with other departments to resolve member or provider
claims adjudication issues.
* Responds in writing or telephonically to internal and external
customers in a professional and diplomatic manner while protecting
confidentiality of sensitive documents and issues.
* Plans, organizes and prioritizes assignments to comply with
performance standards, corporate goals, and established guidelines
* Assumes responsibility for maintaining clinical competency, for
example attending pertinent medical conferences, workshops, and
seminars relating to current medical practices, procedures and
healthcare industry on at least an annual basis.
* Possesses a working knowledge of clinical coding applications, as
* Participate in courses and continuing education to maintain
licensure and applicable certifications.
* Knowledge of medical and surgical procedures and other healthcare
* Competency to apply clinical expertise to ensure compliance with
medical policies and/or reimbursement policies.
* Ability to read and interpret medical records and patient data
and communicate effectively with clinical and non-clinical
* Excellent computer skills and proficiency working software
programs (i.e. Microsoft Word, Excel, and PowerPoint); learn new
processes and systems quickly.
* Strong verbal, written and interpersonal communication and
customer service skills.
* Ability to work in rapidly changing environment.
* Strong research, analytical, math and problem-solving skills.
* Ability to work independently; detail-oriented.
* Must be able to multi-task and set priorities with minimal
Normally to be proficient in the competencies listed above
Payment Integrity RN would have an Associates or Bachelor's Degree
in Healthcare and 3 years of experience in a clinical setting,
health insurance, coding/claims review, case management or
equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Must have an unrestricted Registered Nurse license within either
OR, WA, ID or UT and at least 3 years (or full time equivalent) of
direct clinical care
Additional Preferred Certification: Certified Professional Coder
certified with the American Academy of Professional Coders (AAPC)
or the American Health Information Management Association
Regence employees are part of the larger Cambia family of
companies, which seeks to drive innovative health solutions. We
offer a competitive salary and a generous benefits package. Regence
is 2.2 million members, here for our families, co-workers and
neighbors, helping each other be and stay healthy and provide
support in time of need. We've been here for members for 100 years.
Regence is a nonprofit health care company offering individual and
group medical, dental, vision and life insurance, Medicare and
other government programs as well as pharmacy benefit management.
We are the largest health insurer in the Northwest/Intermountain
Region, serving members as Regence BlueShield of Idaho, Regence
BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of
Utah and Regence BlueShield (in Washington). Each plan is an
independent licensee of the Blue Cross and Blue Shield
If you're seeking a career that affects change in the health care
system, consider joining our team at Cambia Health Solutions. We
advocate for transforming the health care system by making health
care more affordable and accessible, increasing consumers'
engagement in their health care decisions, and offering a diverse
range of products and services that promote the health and
well-being of our members. Cambia's portfolio of companies spans
health care information technology and software development; retail
health care; health insurance plans that carry the Blue Cross and
Blue Shield brands; pharmacy benefit management; life, disability,
dental, vision and other lines of protection; alternative solutions
to health care access and free-standing health and wellness
This position includes 401(k), healthcare, paid time off, paid
holidays, and more. For more information, please visit
We are an Equal Opportunity and Affirmative Action employer
dedicated to workforce diversity and a drug and tobacco-free
workplace. All qualified applicants will receive consideration for
employment without regard to race, color, national origin,
religion, age, sex, sexual orientation, gender identity,
disability, protected veteran status or any other status protected
by law. A background check is required.
If you need accommodation for any part of the application process
because of a medical condition or disability, please email
CambiaCareers@cambiahealth.com. Information about how Cambia Health
Solutions collects, uses, and discloses information is available in
the health of our communities and employees during the COVID-19
pandemic. Please review the policy on our Careers site.
Keywords: Cambia Health, Tacoma , Payment Integrity RN, Healthcare , Tacoma, Washington
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